We are fat, sick and tired because of the way we live. Doctors agree in theory that a healthier lifestyle is the key to prevention. But in practice they rely on drugs. The sane solution is being serious about tackling the cause.

By Jerome Burne

It’s hardly news that things have not been going well for various professional elites lately. Economists so busy promoting the neo-liberal agenda they failed to notice the on-coming depression; politicians resolutely deaf to constituents’ complaints that generosity to those at the top had destroyed jobs and cut wages at the bottom. Trump and Brexit were among the malign consequences of a failure to listen or consider alternatives.

Less widely recognised is that parts of the medical profession have shown a similar readiness to gloss over patient dissatisfaction with the marginal benefits of various widely prescribed drugs or officially approved diets.

Recently one of these MAWPAMS (middle-aged, white, privileged males) had had enough of the whinging about statins – the most widely prescribed and controversial drugs ever. Dr Steven Nissen, a senior American cardiologist, had an article published in the Annals of Internal Medicine, with a headline that a Daily Mail sub could be proud of: Statin Denial: An Internet-Driven Cult With Deadly Consequences. He bemoans the: ‘Internet propaganda promoting bizarre and unscientific criticisms of statins….. As a result, statin adherence rates are extremely low, despite their well-documented morbidity and mortality benefits.’

There are so many misconceptions in this confection that dealing with them could take up the rest of this post so just a couple of quick ones.

Statins and their secret data

Many of statins’ most vocal critics are themselves smart and very well informed clinicians or researchers and their criticisms, far from being ‘bizarre or unscientific’, are based, among other things, on the failure of the statin research to follow the basic rules of evidence based medicine. Although the data collected in drug company trials is supposed to be available to independent researchers, nobody unconnected to the pharmaceutical companies making statins has ever been allowed to see the raw data.

Nissen’s tirade is also remarkably revealing about what is actually going on. It begins by bemoaning a failure of his profession but rather than accepting any responsibility, he pins the blame on a very unlikely source. ‘We are losing the battle for the hearts and minds of our patients to websites developed by people with little or no scientiﬁc expertise, who often peddle ‘natural’ or ‘drug-free’ remedies.’

Really? How amazing is that! Nissen and his elite professional colleagues control the levers of a billion dollar commercial and PR industry designed make sure that not only the profession but everyone is aware of statins’ benefits. It produces the research, ensures that they become a central plank of public health policy, while guidelines committees routinely lower the criteria for getting a prescription.

And yet this great and massively funded army is being defeated by people with little or no scientiﬁc expertise, peddling natural remedies. Doesn’t that sound like a bleat from elite that has badly lost touch with the people it is supposed to be serving? Could it be that it is not the ignorant sandal-wearing bloggers who are deluding patients with their siren-lure of natural remedies, but the fact that patients can read well-informed research about statins, notice how their bodies respond and have developed a healthy scepticism of drug company data?

Bizarre and unscientific medicine

And what a coincidence that just a couple of weeks later NICE announced that according to their algorithm for deciding who should be getting statins – ‘almost all men over 65 and all women over 75’ should be taking them.

That certainly sounds both bizarre and unscientific – you need to treat 150 to 200 patients who haven’t had a heart attack (that is most of those getting a prescription) for one of them to benefit.

The article was largely about the cost of this further extension of prescribing but it did point out that ‘only 31% of eligible people actually complied’ with the much stricter algorithm (20% risk vs 10% risk) set in 2007. So these ignorant nutritionists have been successfully peddling their dangerous creed for at least a decade.

It would be hard to find a more succinct statement of why the MAWPAMs are heading for a fall. Arrogance and refusal to consider they might have got anything wrong, contempt for their patients, countering criticism with insults and denigration and dismissing the idea that nutrition can offer any solution to our epidemic of lifestyle disorders.

Intimately connected with the message to get as many people on statins as possible is the long-standing, but now increasingly discredited, advice to avoid saturated fat because it raises bad cholesterol levels which clogs up your arteries, putting you on the road to heart disease.

Put patients on the board

But just as patients are turning a deaf ear to statin advice, patients with diabetes, among other disorders, are increasingly pushing up their fat consumption and cutting back on carbs as an effective way of losing weight and bringing down their dangerous levels of glucose and insulin. A shift from fat to carbohydrates as significant risk factors for diabetes undermines the logic of cholesterol lowering with statins and so threatens for the ability of the MAWPAMs to retain their hegemony of cardiology.

Of course no one is suggesting patients take part in a debate about the intricacies of heart surgery or engage in the pharmacology of clot busting drugs, but the ideal of ‘no decisions about me without me’ was an NHS aspiration back in 2011 and is still as distant in any meaningful sense as workers on the board.

Talk about lifestyle medicine and patient safety is meaningless when research agendas – what proportion of a billion pound pot to find a way of slowing down Alzheimer’s progression should go on prevention? – are decided without a patient in the room. Same for questions such as: How seriously should we take all the reports of statin or SSRI side-effects? Largely ignore or do some proper stage 4 trials?

This is all pretty much pie-in-the-sky right now – just like re-nationalisation or curbing bankers bonuses was not so long ago – but the mess that the MAWPAMs are making of supposedly paying more attention to benefits of lifestyle changes as a way of tacking chronic disease suggests that giving formal and serious attention to patients wants and experiences is sorely needed.

Turning back the clock by sixty years

A fine example of how the MAWPAMSs can get it very badly wrong in nutrition was the recent attempt by the American Heart Association to turn back the clock on the science of saturated fat to sixty years ago. This seemed to be an attempt to stem the low carb tide that threatens to swamp their long standing low fat advice. It ignored not only about a dozen large scale studies run subsequently that found no risk but also (and arguably as important here) the positive testimony about the benefits of low carbs from tens of thousands of patients.

Using data from the 1960s (!), the AHA produced a report reasserting that that saturated fat was dangerous and that replacing it with polyunsaturated vegetable oils was still the best road to health. However the studies it relied on were astonishing poor.

It involved just four trials – apparently the numerous and largely negative studies done since weren’t reliable. The lax way just one of this historic quartet was done, supposedly the best of a very big bunch, mean it would never been published today.

The researchers knew who was getting which diet and those getting a low fat diet were getting half the amount of sugar of those in the control group as well support and information denied to those eating more fat. Nonetheless the BBC reported it as a warning that coconut oil and avocados could increase your risk of heart disease. Patients knowledgeable about nutrition on the AHA board might have avoided this farrago.

Lipstick on the face of a gorilla

So it’s clear that if you want to cut your chances of obesity, diabetes and heart disease with lifestyle and nutritional changes the MAWPAMs model of health has very little to offer.

And that was before a paper in the Lancet published two weeks ago reported that 30% of Alzheimer’s cases could be prevented simply by paying attention to various lifestyle factors. (Available free here). At first sight you might have thought this was good news, sign of a welcome change. Questionnaires often find patients say they would prefer lifestyle to pills for chronic disease. Maybe (more blue-sky thinking) 30% of the eye watering budget for a successful drug could be allocated to lifestyle?? Currently it is less than 3% of the comparatively tiny charity research budgets.

In fact this was a desperate attempt to put lipstick on the face of a gorilla. Even though the drug cupboard is bare and has been for decades, officially available as lifestyle options – the sort promoted by the Lancet – are pathetically and grossly under-researched. Far from being good news this report would mark the moment in an air disaster movie when a reassuring voice tells passengers that the cabin crew will now be taking over the controls. MAWPAMs medicine at its worst.

The Lancet paper identifies these as the behaviours/conditions that raise our risk so to get that 30% drop in risk we must move them in a positive direction: hearing loss, low education, smoking, depression, lack of physical activity, social isolation, high blood pressure, obesity and diabetes.

Alzheimber’s: the perfect storm

They may indeed all the linked with Alzheimer’s in some way but the point is that they have all been linked with poorer heath for decades; we’ve endlessly been warned to tackle them if we want to age well and all the while their rate has gone up and up.

Alzheimer’s is the perfect storm for our current medical model which spends billions on researching and promoting pharmaceutical solutions and essentially considers nutrition and lifestyle options a very poor and ineffectual relative. The result is that non-drug approach is looked at through the pharmaceutical lens which means you have to test each potential treatment one at a time with a vastly expensive RCT.

Not only is the funding not available for this but it would most likely be pointless. The one thing the Lancet list does is vaguely to point to the fact that Alzheimer’s is the result several systems in the body that are not functioning well. But there is no sense of why or how best to tackle them. Certainly attempts to cut weight, increase exercise and reduce incidence of diabetes has made no progress at all.

So what could be done by picking up on a few of the new and promising tools outside this very old box? Two suggestions out of many. The Lancet report, and a similar one recently published in America by the National Academies of Sciences, Engineering and Medicine, both pick up on the fact that Alzheimer’s patients have high levels of insulin in the brain and that Alzheimer’s could be a sort of metabolic disorder like T2 diabetes

The trials that were designed to fail

So since the official low fat diet does little to lower glucose and insulin why not run a proper trial with a low carbohydrate diet, which is already being used with great success by a growing number of GPs to treat their diabetes patients?

That could be combined with a second option – high dose B vitamins– which is the only potential non-drug treatment that has been put through a full-scale randomised trial. The Lancet paper dismisses it in a sentence, saying that the study, which used brain scans to show a remarkably impressive slowing of brain shrinkage, had not shown any cognitive improvement. This is simply not true says the lead researcher Oxford professor emeritus of pharmacology David Smith.

Just as with the statin saga there is long and disreputable story behind that brief incorrect and dismissive sentence which I’ve covered here.

Essentially, several follow up studies were done on Smith’s work but it is a reasonable assumption that they were all designed to fail. The original trial gave high doses of B vitamins to people who already had early memory and thinking problems and (this is important) who also had high levels of an amino acid called homocysteine that is linked with heart disease and Alzheimer’s risk.

The shameful thing is that none of the failed follow up trials did this. They either gave the vitamins to healthy people or they failed to measure their homocysteine levels. The fact that promising and very plausible research has never been properly followed up should be a public scandal.

Despite the lack of a proper follow up Smith continued smaller scale studies and discovered exactly the sort of connection you would expect if there were multiple process involved in the road to Alzheimer’s. Patients who had high homocysteine and got B vitamins benefitted, but only if they also had a good level of omega 3 fatty acids. Combining that with a low carb diet rich in omega 3 gives you a promising protocol that is a world away from the familiar injunction to eat a ‘balanced’ diet

It’s also not going to make it to the starting block under the regime of the MAWPAMs.

Jerome Burne

Jerome Burne is the editor of HealthInsightUK. He is an award-winning journalist who has been specialising in medicine and health for the last 10 years and now works mainly for the Daily Mail. His most recent book “10 Secrets of Healthy Ageing” was written with nutritionist Patrick Holford. He blogs at “Body of Evidence” – jeromeburne.com. 2015: Finalist for 'Blogger of the Year' award from Medical Journalists' Association.

Agree but it is hardly controversial note that males outnumber females at the top of professions such as banking, politics and medicine. My point, perhaps not made clearly enough, is that while the the failings of those at the top of banking and politics – routinely described in terms such as ‘elderly white males’ – are very familiar, the similar systemic failings in medicine in the way chronic lifestyle diseases are handled isn’t thought of in the same way yet.

By using similar terminology to describe those at the top I hoped to highlight failings in the system that are usually seen as problems in a particular area of medicine – heart disease/Alzheimer’s rather than part of a more general one. Hope you can ignore this tree and pick up on the forest.

Having suffered the effects of statins (which fortunately vanished after I gave up this wonder drug) I most certainly endorse the rest of your message

I just think we should avoid stirring politics into the discussion unless it is explicitly relevant. As far as I am aware no political party (or sex) has said anything about the scandals you are talking about. I tried to get UKIP interested, but without success, I am sure other politically active people have made similar attempts with ‘their’ party. The problem is that politicians see this as a purely medical problem, when in reality it is about politics – how research organisations are funded, and how they can hide data, etc.

Agree it is not on the political agenda but i would argue that it precisely why the point should be raised. Given the huge human and financial cost of trying to fix lifestyle disorders with pharmaceuticals (not saying they don’t have a role but except in a few cases they are usually an inferior option for prevention) it should be an integral part of the ongoing debate over the direction and funding of the NHS. It seems a natural Labour issue; given that the Tories are very keen to privatise large swathes of the service they don’t seem such a natural fit.

Thanks but the Trump point is hardly wild guess. It’s now a commonplace that there was a constituency that neither of the main parties were appealing to who form his core supporter base. Or do you disagree that the result of his election was malign? Undoubtedly many other factors.

As a matter of interest, do you consider the claim that the behaviour of banking sector lead to a wide distrust of bankers equally subjective? My intention was to widen out the debate so we move on from complaining in silos – statin advice poor, dietary advice poor etc – and a good way to do that seemed to be to focus on the guys (mostly guys) at the top.

Absolutely – without getting critiques of standard medical approach into the mainstream and presenting alternatives it will remain a niche activity. What makes it hard is what might be called the ‘tobacco effect’. Every time there is a well publicised critique on the likes of the dangers of saturated fats or the failure of the low fat diet for diabetes, an ‘authority figure’ is wheeled out to counter it. In general people prefer to believe respectable medical figures so confusion remains.

The same technique kept people uncertain about benefits or otherwise about tobacco for years and about transfats and still about sugar.That’s why i have long felt that the pressure needs to come from doctors. Having a significant number rebel over low fat for diabetics has definitely had an effect. The diabetes example also shows the power of organised patient reports, such as those produced by the patient’s website diabetes.co.uk.

Do doctors give a damn about informed patient consent? I doubt many people would take statins if they knew that they had one chance in 150 – 200 of benefitting and a much greater chance of suffering possibly serious adverse effects. My brother was losing his memory when he was taking this ‘medication’.

So, how many patients give informed consent to statins? I’m told that in many nursing homes every resident is on statins. In 2015 the Supreme Court strengthened the law on consent. Here is part of the judgment:

• The patient must have sufficient information to make a choice – without adequate information, patients are unable to make decisions about their treatment. The information provided should, for example, include: an explanation of the investigation, diagnosis or treatment; an explanation of the probabilities of success, or the risk of failure; or harm associated with options for treatment. The patient should be given time to ask questions. The GMC and the courts expect patients to be given all information material to their decision, with the proviso that it would not cause the patient serious harm.

• The patient must be able to give their consent freely – pressuring patients into consenting to treatment invalidates the consent. To ensure that consent is freely given, patients should, where possible, be given time to consider their options before deciding to proceed with a proposed treatment. Be aware, too, that patients’ friends and relatives may also try to exert their influence and that this can be subtle but nevertheless powerful.

I doubt that 1% of people taking statins have given true consent. Another silent scandal.

Agreed! If there was a rule that the NNT (which sidesteps the relative vs absolute gain issue) must be given to the patient – as accurately as possible for the patient’s condition – hardly anyone would take these drugs. No system will ever be perfect, but patients should be presented with the data in an agreed format.

Excellent point. Consent is the only real power a patient has. Legally and morally, it should be informed consent. Are we really supposed to believe that every elderly patient in a nursing home is giving informed consent to take a statin? This is doctor decides.

The Number Needed to Treat (NNT) for one patient to benefit is a big help to patients. Relative risk is meaningless and is nothing less than propaganda.

HW, what utter guff. I’m a working class male and I bet you’ve seen a lot more ‘privilege’ than I have. “Check your privilege” is juvenile university nonsense, unworthy of an adult. Present an argument, not a slogan.

Why would I bother to debate with a man who cannot mind his manners? You know nothing about me.

Such an irritable response is telling in itself. The mention of male privilege in the title of the article is what drew initial negative, responses from male readers, over and above the substance of the article. As a woman who has has to deal with the medical profession – including the almost exclusively male upper echelons – for nearly 40 years, the writer’s references to the impact of male decision-making within the profession certainly struck home. So, check your privilege. Or examine it, if you prefer.

You have been warned before about your readiness to reach for an insult rather than an argument Stephen T. You are welcome here providing you follow common courtesies and add something useful or pertinent, otherwise it will down the chute to the trash for you.

Bit off topic regarding the MAWPAMSs issue but isn’t it true and becoming more so? It seems to me that all ‘professions’ are in the pay of the Sheriff of Nottingham to use an analogy . Lawyers, some doctors, bankers, renewable energy, Pharma, big business, farmers etc etc. We earn the money they suck it up directly or indirectly and seem to scream for more (King Crimson). Not surprising that we’re all skint these days.

The MAWPAMS acronym seems to have taken on an unfortunate life of its own, which is distracting from the point of the piece. I didn’t think there was anything controversial or novel about saying that the various professions that make up the ‘establishment’ which is where power in the country largely resides, contains more males than females, who are mostly likely to be white and who necessarily form an elite and who, by virtue of their power (and very likely by birth) enjoy considerable privileges.

I also thought it generally accepted to say that this group got it badly wrong on economics and in politics, which didn’t rule out failures in other fields. My point was not to say that every profession is corrupt or bought and paid for but that those at top of the medical tree had somehow escaped censure. I then set out some of the areas that should be cause for concern.

So could we move on from MAWPAMS and discuss if that is the case, then what needs to be done? For instance, rather than relying of the abstract notion of evidence based medicine to correct imbalances and prevent the clinging on to discredited theories, do we need some sort of independent body to decide when it is time for a change or would that simply become a bloated bureaucracy equally vulnerable to regulatory capture.

Well, using statins as an example, as I said above, I’d suggest a simple requirement that patients must be informed of the NNT for each medicine they are prescribed – or at least each long term preventative medicine, such as statins.

Perhaps some data on the side effect rates would help too – e.g. the percentage of people who stop taking the medicine because they report problems. The important thing would be that this would be the raw data – not data fiddled with by the ‘experts’. If you chat with people about statins, you hear all sorts of unpleasant stories, and huge numbers of people give them up because of the side effects.

It is surely inconceivable that many people informed of the statin NNT (even after a first heart attack) would be willing to accept the treatment.

As far as I can see, any ‘independent body’ will simply be infiltrated by the tentacles of the pharmaceutical companies like the rest of the medical establishment!

Time has come to say goodbye Stephen T whoever you are, although it would be reasonable to assume you are a supporter of the militant vegan lobby. Do read the incisive critiques its latest promotional video has been receiving. i was interested to read that the lobby is supported by the millenarian Protestant sect the Seventh Day Adventists, a group that waits eagerly for the Second Coming.
The warning that you will no longer be welcome here if you continued to reach for an insult rather than an argument, the one you can’t remember, was given two days ago on Aug 16.
Subsequently HW commented that from her medical experience the MAWPAMS acronym was “entirely appropriate” and suggested you “check your privilege”. A phrase that i found unclear but was in no way offensive
You replied that this was ‘juvenile university nonsense’ mild but which, typically. contributed nothing to this blog.
To which HW responded, remarkably reasonably in my view, ‘Why would I bother to debate with a man who cannot mind his manners?’
Which you then described as ‘brainless waffle and jargon’. Not wildly offensive but totally inaccurate and more play=ground name calling.
The idea the HW’s comment ‘insults half the male population’ is again absurd. She, along with the whole MAWPAMS post was concerned with senior members of the medical profession. I am mystified as to why you feel it has anything to do with you and all other males. I’ve responded to other comments on the acronym here.
So further comments from you – unless they are calm, thoughtful and interesting – will be trashed.

On the 16th August you referred to a previous warning of which I’m completely unaware and which you haven’t located. I don’t think it exists.

You have somehow concluded that I’m a militant vegan. I have regularly criticised their approach on this site and never supported them in any way, shape or form. Indeed, I regard them as blinkered fanatics. I am fully with Dr Gary Fettke, Tim Noakes and Zoe Harcombe. I have no idea how you managed to arrive at such a wholly false conclusion, unsupported by any statement that I’ve ever made on the subject. I had steak and eggs for tonight’s meal. I’m not sure where you think that places me on the vegan spectrum.

You introduced the divisive privileged male stuff, which David Bailey rightly criticised. HW then told all us men to “check our privilege”. This meaningless phrase is applied to all men, most of whom have never seen a smidgeon of privilege. If you don’t think that’s insulting, I do.

Stephen T – many apologies I’m afraid I confused you with “matthew” a sometime contributor who is angrily opposed the low carb appraoch and firmly committed to the superiority of veganism and has a habit of combining his objections with gratuitous insults. I now see that you have made a number of useful contributions which I appreciate. What confused me – I confess i did respond rather too speedily – was that you did seem to be taking a rather dismissive tone in disagreeing with HW. Be grateful if you could disagree courteously.

On the privileged point, I really don’t understand your point that it defames all males when it was very specifically targeted at very senior doctors who have far more in common with very senior figures at the top of other professions than they do with the rest of the male population. I am elderly, white male and have benefited from a degree of privilege but am no senior medic so am not dissing myself. I also have a number of colleagues who could be described in a similar way but who are also not top doctors and so not included. I recognise your disagreement but please no more discussion on it. A very minor point that has unfortunately distracted from the main point of the post.
Apologies again for the identity confusion.

David, the phrase is definitely derogatory. It’s used to shut people up. I asked a student who I heard using the phrase to explain what she meant by it. She hadn’t a clue, but she used it in an attempt to shut someone up who was making an argument she didn’t like.

It’s like saying you have no right to an opinion. It’s part of a deeply divisive agenda and is almost always used to enforce compliance.

For what its worth I continue to disagree with the “derogatory” point – see below for reasons – and without wishing to be rude – your example of a woman using it to shut someone up having admitted she didn’t know what it meant, is not convincing evidence for your claim.
I do understand your pain about being confused with Mathew, however, and apologise again

Understand you don’t like the ‘privileged white males’ phrase but I am really puzzled as to why you think it applies, as far as I can tell, to pretty well anyone who has any degree of privilege such as being born into wealth or position and is old – 60? 65? 70? and is white. It does not. As I have written on a number of occasion, I was referring specifically to a small select and powerful group who are of medics who are perfectly able to take care of themselves. So unless you are worried about the sensibilities of senior male consultants it would be great if you stopped going on about it.

As for politics the whole point of the piece was to point out that you can’t extract politics from the priorities of the NHS so no I disagree that we have to take politics out of the discussion. Instead, as the post deliberately implied, that is one of the things that is needed for the damaging concentration on a pharmaceutical approach to dealing with life-style disorders to be shifted. It is not the only solution but a party that wanted to put more money into promising non-drug approaches – read the original post for ideas – would be a useful start. As we all know the NHS was a political invention. No amount of studies showing what a beneficial idea it was would have established it.

You may mean one thing by the phrase in question, but it is often used in the way I described by impressionable young women. In the real world it’s not used at all. Perhaps medicine and nutrition have
enough controversy without adding another ingredient.

Democratic deficit is one of the most appropriate terms that you have ever used, Jerome. MAWPAMS is one of the least appropriate.

It doesn’t matter what description is befitting of the people in the upper rankings of the pyramids of power and influence half so much as it matters that they can be inclined to be stubborn, ill-informed, don’t bring enough cause-oriented concern to the party, can be lazy thinkers, are set in their ways, and they impress patients with half-baked hypotheses and explanations Hence we could argue all day long about whether MAWPAMS is a justified term but it neither highlights nor resolves those matters that matter most.
Yes there exists a democratic deficit in a number of affairs. What matters most is what factors and circumstances give rise to them. That the people ensconced in the higher places of the pyramids of influence and power may tend to fit the description of MAWPAM is more incidental than it is causal. The industrial revolution happened here first, in England, and rippled out first through the English speaking world as did the economic growth that followed. Economic growth is what permits the growth in diversity of economic activities in the trend to sophisticated and post-industrialised societies. It is because it happened here first, a function of history, if you like, and discrimination between the sexes, that MAWPAMS filled roles in those growing pyramids of power and influence. Why did the industrial revolution have origins seated in England? Reasons both geological and maritime. Coal seams sat close to the surface geology near the port of Newcastle and coastal shipping routes meant this fossil fuel could be distributed to other ports such as London, Liverpool, and Manchester etc.

These democratic deficits may be several, BTW, but a lot of the time they pass unnoticed and do so because people are afflicted by some key cognitive deficits. They simply do not know enough to notice. This affliction is not confined to lay people, experts fall foul as well. There is not one human alive that does not suffer from one cognitive deficit or other. Einstein, for instance, struggled to grasp the uncertainty principle that is now an accepted facet of quantum physics. The one cognitive deficit that trumps all others is that so many people, economists included, think they understand all that exists to be understood about money. Almost certainly the majority do not understand all that exists to be understood about money. If only people good recognize a good steer when they are offered one then read enough and think enough to redress their cognitive deficit the world could be a completely different place. When the root of the problem is humans having a limited concept of money the solution is no more radical than humans in sufficient numbers taking purposeful and necessary steps to expand their concept of money.http://www.moneyasdebt.net/

By the same token patients and medical professions have at best only a limited concept of fats and cholesterol. The explanation for why the fat/cholesterol hypothesis for cardiovascular disease IS WRONG generally rests in that cognitive void that is their cognitive deficit. They have precious little concept of what a cholesterol oxide may be, no knowledge of how many oxides are possible, and no knowledge that certain of them can better account for the kind of changes to be witnessed in arteriosclerosis than cholesterol itself can.

The summary message is that the way economies evolve mimics natural evolution. Affairs trend to more diverse and increasingly sophisticated. The trouble is that falsehoods can enter the fray and pass for the truth and that adds new levels of complication and consequence. Despite these trends are man-made men, be they MAWPAMS or not, and women, struggle to perceive what ranks as an undesirable effect and what may give rise to them.

Thanks for the wide ranging comment. ‘Most inappropriate’ seems a little harsh although, as i have discovered, it seems to distress/annoy people for reasons that still elude me. It was intended to be analogous to the phrase “dead white males” used to describe the authors of traditional anglo-american literature and described as being ‘designed to serve the ideological aims of a conservative and repressive Anglo hegemony.’ My lot are alive but the the intention to pin-point where the power is located is similar. You say the term MAWPAMS neither ‘highlights nor resolves those matters that matter most.’ I would argue that it highlights the problem in a useful way but certainly does not resolve it. Certainly agree with you about the socio-economic-geographic factors that put them there and with their unrecognised cognitive deficits.

1) Scientific debates are not won by a democratic process. If medical science is ever to establish new ideas about cholesterol/saturated fat/statins, it will be because a tiny number of people forced the truth down the throats of an unwilling majority! Think of Barry Marshall, who eventually forced the truth that most gastric ulcers are caused by bacteria, down the throats of hoards of medical researchers happy taking grant money from the companies that made antacid treatments!

2) To me, the fundamental idea of a multiracial society should be that a person’s race does not matter. In that context, using the word ‘white’ as you did is deeply offensive.

3) Something similar applies to the issue of gender. If girls and boys are to feel free to aspire to (almost) all jobs, they don’t want to read that men (or women) are a problem.

4) The problems in medical science and, I think science in general, don’t seem to relate to those political issues at all. They seem to be the result of an incredible group-think, reinforced by the way grants are awarded and the process by which papers are refereed.

As a result, the first part of your paper didn’t make sense, and offended a lot of people, but the rest of it was obviously, eminently sound.

The original article was an attempt to explore some new ways of addressing the blind spot our medical establishment has around preventing chronic disease – heavy promotion of pills; lip service to lifestyle change. An obvious starting point was to point up the democratic deficit; this establishment is headed by the same narrow clique – white privileged etc – who, it is widely agreed I would argue, have not done a great job in the likes of banking or politics but who, it seems, has escaped censure for their running of medicine.

It’s a nice idea that science will ultimately triumph but bringing the ruling clique into the picture was intended to make the point that where and how money is spent in medicine is essentially a political decision – just as it is for utilities or social care. Hence the need for greater democracy in a conventional sense.

But the democratic point goes further. None-drug approaches have been very successfully hobbled by the notion that the only way to change medical practice is with scientifically gathered evidence. Of course reliable and effective ways to evaluate the safety and effectiveness of treatments are needed. But it is very clear that in areas of prevention the system is geared to produce results that favour the pill approach. What I am arguing for is giving more power to patients; bringing them in a active participants rather than viewing them as passive recipients of the latest product from the drug labs. (And this is not an argument against drugs as such but as the first resort for prevention)

The clearest example of how this can work is going on at the moment with diabetes – a topic that has been covered extensively here. Essentially it is about numbers. The official line is that only an RCT can give you reliable results. In fact there are dozens of RCTs supporting the use of a cupboard-full of diabetes drugs and yet more and more people are developing the disorder and none of the drugs actually cut the risk of developing the damage that comes with diabetes and which is usually the actual killer.

The increasingly widespread use of the low carb diet to treat and prevent diabetes was not triggered by drug company RCT’s It gathered momentum because thousands of people with diabetes following the diet and then posted the frequently remarkable results on line at diabetes.co.uk. Five people. Ten people. A hundred may be dismissed as unscientifically irrelevant anecdotes but 10,000 cannot plausibly be dismissed in the same way. Making prevention a political issue involving tax payers money and involving patients could bring about change on the scale that the officially sanctioned evidence gathering is never going to do.

Again, I agree with all except your first paragraph. I mean just suppose a real political campaign were to be constructed around the supposed need for a of purge medical research to remove MAWPAMS – both you and and Malcolm Kendrick would have to go, just for starters! Then the pharmaceutical companies would seek out black female medical researchers and ply them with gifts to bend them to their cause. Absolutely nothing would be achieved – indeed things would probably become worse.

I am actually amazed – and gratified – by the extent that people (at least those I know) are becoming aware of the scandalous fact that medical science and NHS advice is not always serving them well.

I would much rather see a grass roots campaign centred around the real issue, which isn’t bad science so much as corruption. Curiously, the damage that the advice on saturated fat consumption might have done, was mitigated somewhat by ordinary people whose gut instinct told them that real, traditional food was better for them – they would eat “heart attack on a plate” meals, while the trendy middle class would laugh at them. They are the ones who helped maintain a market for butter, salt, eggs, fatty meat etc.

Perhaps at some point greater numbers of doctors would begin to contemplate their own experiences and also join this movement

I don’t know if such a campaign would succeed, but at least it would be aimed in the right direction. I mean if we are to talk politics, lets discuss something practical!

The term I used was ‘least appropriate’ and did so in a comparative context having praised you for the use of the term ‘democratic deficit’.

It was our use of ‘democratic deficit’ that prompted me to think of ‘cognitive deficit’ and see it potential for in another setting and offensive. Hence I am very grateful for your article and stimuli while you would not be able to gauge how much.

If folks need to get a better grasp of the problems that give rise to democratic deficits in the delivery of prevention and/or treatments, and/or we need to explain it, recourse to the term MAWPAMS associates with those problems but does not get a firm grasp on the roots of those problems.

I thought your style and approach here was trending to that of George Monbiot and in my well-intentioned way it seemed fit to discourage that. More a good turn than harsh, I think.